Yash Shroff - Intern, Public Health and Well-being Mandate
The World Health Organisation (WHO) defines sexual health as “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled”. Sexual health includes topics such as HIV/AIDS, adolescent pregnancy, female genital mutilation, STI’s and family planning/contraceptive methods and poor sexual health knowledge can have adverse effects on the life of an individual and the relationship they share with their partner. Poor sexual health can lead to dissatisfaction and unhappiness and is an important aspect of our health, an aspect that needs a lot more attention than actually given. This article aims to briefly touch upon a few aspects of sexual health like STI’s, family planning and adolescent pregnancy to show that there is still lots of work to be done in the field of sexual health to ensure that the sexual rights of all human beings are respected so they can live happy and healthy lives.
SEXUALLY TRANSMITTED INFECTIONS
In 2016, the WHO estimated that approximately 1 million STI’s were acquired worldwide in a single day. There are 8 pathogens that are linked to the highest number of STI’s. Of these 8 pathogens, four are treatable and four are not. While chlamydia, gonorrhoea, trichomoniasis and syphilis are treatable, HIV, hepatitis B and herpes and HPV are untreatable although with proper medication and treatment, their severity can be reduced.
WHO estimates that about 500 million people are living with genital herpes and more than 300 million women have an HPV (Human papilloma virus) infection which is the primary cause of cervical cancer. An estimated 240 million people are living with chronic hepatitis B virus worldwide. However, HPV and hepatitis B are preventable with vaccination. The reason why these diseases are of concern and must be taken seriously is because they have consequences which are beyond the immediate impact of the disease. Having an STI can further increase one’s probability of contracting HIV by three-fold or more. Further, STI can be transmitted from the mother to the child during pregnancy which can result in stillbirth, neonatal death, low-birth weight, prematurity, sepsis, pneumonia, neonatal conjunctivitis, and congenital deformities which can even lead to death of the child. According to WHO, if the STI’s are undetected and therefore untreated, they can lead to neurological and cardiovascular diseases and also infertility, stillbirths and increased chances of HIV. Therefore, it is absolutely essential to use condoms consistently as they help protect against HIV and STI’s.
According to the National Health Portal, a study conducted by the ICMR in 2002-03 showed that 6% of the population in India has one STI but with the population of the country, it amounts to around 35-40 million people. Since these diseases not only affect health directly but are also associated with stigma and domestic violence, they can severely affect the quality of life.
FAMILY PLANNING AND ADOLESCENT PREGNANCY
According to the National Family Health Survey - 4, (NFHS - 4) 7.9% of women in the age range of 15-19 years were either already mothers or were pregnant with their first child. The prevalence was much higher in the rural areas (9.2%) as compared to the urban areas (5%) with Tripura leading the states (18.8%). In the National Family Health Survey - 5, 21.9% of women in Tripura, in the age group of 15-19, either had a child or were pregnant with one which shows that the rates of teenage pregnancy have increased in the state which needed interventions the most. As per the NFHS - 4, Lakshadweep had 0% of women in the age group of 15-19 give births in both, the rural and the urban regions. However, in NFHS - 5, 5.1% of women in the rural areas in Lakshadweep, belonging to the concerned age demographic gave birth to a child or were pregnant with one. According to NFHS - 4, 51.5% of married woman around 15-19 years of age have already begun childbearing. This number seems to be increasing.
Education and teenage pregnancies are inversely related to each other. According to NFHS - 4, in the age demographic of 15-19 year old women, a larger percentage of women who have received little or no schooling have begun childbearing as compared to those who receive 12+ years of schooling (20.2% versus 4.4%). Women who have no schooling give birth to, on average, 3.07 children as compared to the women who would give birth to 1.71 children.
According to WHO, teenage pregnancies can have significant health consequences for the mothers and their babies. Adolescent mothers, aged 10-19 years, face a higher risk of diseases such as eclampsia, puerperal endometritis and systemic infections as compared to pregnant women aged 20-24 years. According to WHO, there are additional 3.9 million unsafe abortions which may lead to maternal mortality, morbidity and lasting health problems. Not only does teenage pregnancy have consequences for the mother, but if the adolescent does decide to go ahead with the pregnancy and give birth, it can lead to increased infant death, stillbirth, low birth weight, deficits in social development of the child and neonatal death. As per NFHS - 4, around 14% of births are non-live births in women 15-19 years of age. As per the same survey, when the mothers age was less than 20 years, infant mortality was 52.1 while neonatal mortality was 38.7, highest among all age groups except women whose age was between 40-49 years.
A paper published in 2014, by the Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, highlighted not only the health but also the psychological consequences of teenage pregnancy. Adolescent mothers tend to be less knowledgeable regarding child development, have poorer parenting methods, greater maternal stress, and are also less likely to form a stronger emotional bond with their infant. The emotional bond is formed by smiling, kissing, hugging their infant, which the adolescent mother is less likely to do. This may lead to the poor social development of the child. Not only do teenage pregnancies have health and psychological consequences, they also have social and economic consequences. According to WHO, many unmarried pregnant teenagers may face stigma, rejection and even violence by their partners, peers and relatives. Becoming pregnant during their teenage years may cause them to drop out of school or college which can drastically change their life, making them less educated which would take away their employment opportunities and consequently, their independence. In the case a teenager wishes to go ahead with the pregnancy, they must receive antenatal care. The use of a skilled provider for ANC increases with an increase in education. 61% of women with no schooling use a skilled provider as compared to 93% of women with 12+ years of schooling. Antenatal care is extremely important as it helps in screening for any health complications which can have a significant impact on the foetus. Not just antenatal care, but also the place of delivery, skilled professional performing the delivery were all inversely related to the educational status of the mother.
Family planning also plays an important role in certain health and non-health related aspects of a woman’s life. A guide put forth by Johns Hopkins Bloomberg School of Public Health says that it is highly beneficial for the mother and the infant to give birth again only after the youngest child is at least two years of age, which means the mother can start trying to get pregnant 24 months after her previous delivery. However, according to NFHS - 4, 11.6% of women who have received no schooling get pregnant within 7-17 months as compared to 9.9% of women who received 12+ years of schooling. This number increases drastically for mothers between 15-19 years of age (28.9%). Therefore, it is essential for women to focus on family planning. However, there are several problems when it comes to family planning. According to NFHS - 4, only 15% of married women between 15-19 years of age use a contraceptive and only 10% use a modern contraceptive method. While among sexually active, unmarried women, 34% use a contraceptive method and almost all of them (32%) use a modern contraceptive method. (Modern methods include: male/female sterilisations, male/female condoms, diaphragm, injectables, pills, IUDs, lactational amenorrhea method, emergency contraception).
According to NFHS - 4, 93.3% of women who received no schooling were aware of a modern contraceptive method while only 80.6% of women with the same educational status were aware of a modern temporary method as compared to 98.2% of women who received 12+ years of schooling were aware of a modern contraceptive method and 95% of women, of the same educational status, knew of a modern temporary method. It is essential to know that with an increase in education, the awareness of a modern temporary method increases as “female sterilisation” was the most well-known method of contraception, thereby eliminating chances of ever having children in the future. However, in the age group 15-19, of the sexually active unmarried and currently married woman, 83.2% woman in the urban do not use contraceptives while 85.6% in the rural do not use contraceptives. While the rates may be similar, it is important to note that there are around 12000 more woman in the rural areas not using contraceptives. While providing women with the contraceptives, it is important that they all are aware of any possible side-effects, what to do if they experienced these side-effects and any alternate methods. However, only 47% of women using modern contraceptive methods were informed of the side effects and only 39% were told what to do if they experienced side effects.
From the data presented above, it may appear as though education was the solution to everything. While educating an individual does change their perspective and open their mind to new ideas and concepts, in this situation it’s important to focus on the kind of education that is imparted, not just to the students but to the population as a whole, particularly to the students in high school as they hit puberty and enter adulthood. Sex education or sexuality education is a broad term and does not talk only about the reproductive organs and the process of reproduction but delves deeper and talks about healthy sexual development, gender identity, sexual development, intimacy, affection and body image issues for all adolescents serves as a foundation for healthy sexual behaviour which includes age of consent, safe sex practices, sexual pleasure and also contraception. The complex emotional state that the youth finds themselves in during this phase of life, with gender inequality, stigma and different stereotypes surrounding them in matters of sexuality makes sexuality education even more essential in their lives. India happens to have the largest adolescent population (253 million) with every 5th person between 10 and 19 years and so it is absolutely imperative that these children receive the education that will help them maintain their sexual health as they make certain choices and decisions in their life at that vulnerable age.
The current sexual health needs of the youth are not entirely met by the government which could possibly be because of the unpreparedness of the Indian health system of the country. There are certain healthcare professionals who are not trained to communicate effectively about the issues of sex and sexuality education which impacts the way they share the knowledge they have, leaving the youth more confused than before. People do not talk about sex openly as it is considered to be “inappropriate” and a taboo in the Indian culture. The government has banned all condom ads from being displayed on television, which sounds like a wise move for the second-most populous country and a country having the third-highest prevalence of HIV/AIDS. Instead of teaching the youth to be more respectful towards each other, there are politicians defending rapists by blaming it on the stereotype of “men will be men”, a stereotype sexuality education can help do away with.
The point is not to blame the government or point fingers at anyone, the point is to start educating the youth. How many times have you had people give you looks if you ask for condoms at a pharmacy? Or rather, have you ever been able to ask for condoms or contraceptives freely or do you feel a little awkward asking for them? India has been a traditional society but even though things are changing now, the change is not widespread. Chasity has always been highly prized, especially when it comes to women and sex has been treated as a taboo and an unspeakable act. The loss of virginity before marriage and marriage outside sex is considered to bring dishonour to the family and questions the loyalty and character of women. Thus, sex-education is extremely essential to break these taboos and liberate people. Opponents of sex-education believe that it is inappropriate and will offend our values and corrupt the minds of the young children, causing them to take part in irresponsible sexual behaviour. Calling sex as “indecent” and “inappropriate” is not only wrong but also delays the inevitable. As children grow older, they will, one day, experiment and instead of them taking part in sexually risky behaviours, it’s best if we tackle this head-first by giving them the knowledge they need to make decisions that are safe, respectful and healthy. This can occur only if sexuality education is imparted to children in schools, by breaking down and teaching only those concepts and facts that the students would understand at their age and their level of maturity, something called age-appropriateness. Sexuality education needs to be embedded in the curriculum and while that may take a while, schools can start off by having workshops to address these issues. Teachers can be taught how to deal with the questions that arise while teaching the reproductive organs in biology so maybe the questions can be answered and not have the two reproductive chapters cancelled out. India has never had a solid sex-education program and there have been controversies in the past in matters regarding sexuality education. According to the Times of India, the Union Health Minister said that sex education should be banned. Later, in 2018, Prime Minister Narendra Modi revamped the school health education program which focuses on sex education by following an age-appropriate curriculum. However, there yet has not been any significant progress made on that front.
The Swedish model for sex education is one to look up to. The Swedish government has made sexuality education compulsory in schools since 1955 and the different concepts which fall under sexuality education are integrated within the normal curriculum. The program was made compulsory in 1955 and was written in the guidebook for teachers that was distributed in 1956. For example, in history, the students have the opportunity to learn how the views regarding sexuality have changed over the course of history. Geography does not only contain material which teaches students about the types of soil but also has content linked to population growth, spatial change and also looks at reproductive health and family planning when looked at from various perspectives. The curriculum also teaches about religion but teaches the pupils about morals, ethics and human rights and incorporates sex, sexuality gender and gender equality as a part of the curriculum. The interdisciplinary method of teaching allows the students to think for themselves. Unlike India, it teaches the students how to think rather than what to think.
Sexual health is an important component of health and impacts the physical, emotional and mental aspects of health and is essential for the holistic growth of an individual. The knowledge of sexual health also ventures into a human rights issue as by being aware of what an abusive relationship is and what their rights are, they can walk out of relationships that are detrimental to their growth and can be free from sexual harassment and violence and live a life of happiness, independence and satisfaction.
Yash is a third-year at Ashoka University, majoring in Biology with a minor in Psychology. He is passionate about public health and development and wants to study the same in the future. Outside of academics, he enjoys running, cycling, reading and working out. Yash is part of our new Public Health and Well-being Mandate.